original article
Eligibility for home oxygen programs
and funding across Canada
Yves Lacasse MD MSc FRCP, Sarah Bernard MSc, François Maltais MD FRCP
Y Lacasse, S Bernard, F Maltais. Eligibility to home oxygen programs
and funding across Canada. Can Respir J 2015;22(6):324-330.
Background: In Canada, although medical insurance is generally
universal, significant differences exist in the provision of home oxygen
therapy across the country.
Objective: To systematically compare the terms of reference for home
oxygen across Canada, with a focus on the clinical inclusion criteria to
the programs.
Methods: The authors searched the terms of reference of the
10 Canadian provinces and three territories, focusing on general eligibility
criteria for home oxygen (including blood gas criteria, and eligibility crite-
ria for ambulatory and nocturnal oxygen), and compared the eligibility
criteria to the widely accepted criteria of the Nocturnal Oxygen Therapy
Trial (NOTT) trial, the clinical recommendations of the Canadian
Thoracic Society and the results of Cochrane reviews.
Results: The terms of reference for nine provinces were retrieved. All
jurisdictions have similar criteria for long-term oxygen therapy, with slight
differences in the thresholds of prescription and the clinical criteria defin-
ing ‘pulmonary hypertension’ or ‘cor pulmonale’. The use of oxyhemoglo-
bin saturation as a criterion for funding is inconsistent. All nine provinces
fund nocturnal oxygen, all with different clinical criteria. Funding for
portable oxygen widely varies across provinces, whether the ambulatory
equipment is offered to patients on long-term oxygen therapy or to those
who have isolated exercise-induced desaturation. The terms of reimburse-
ment are very heterogeneous.
Conclusions: Heterogeneity exists in the criteria for eligibility to
home oxygen programs and funding across Canada. Terms of prescription
and reimbursement of oxygen are not necessarily supported by available
evidence from the current literature in several Canadian jurisdictions.
Key Words: Chronic lung diseases; COPD; Eligibility; Funding; Home oxygen
programs; Oxygen therapy
T wo landmark trials conducted >30 years ago provided scientific
evidence that, under very specific circumstances, long-term oxy-
gen therapy (LTOT) may prolong life (1,2). These two trials targeted
patients with chronic obstructive pulmonary disease (COPD) and
severe daytime hypoxemia documented using direct arterial blood gas
measurement. A total of 290 patients were randomly assigned: 87 in
the British trial (1) and 203 in the American trial (2). Both studies
focused on life prolongation rather than quality of life, and cost effect-
iveness was not an issue at the time. Thereafter, oxygen therapy
became standard of care in COPD, and confirmatory trials would now
be considered unethical by many clinicians and scientists. New indica-
tions of oxygen therapy in COPD (such as nocturnal oxygen therapy
in patients with isolated nocturnal oxygen desaturation, or ambulatory
oxygen to correct exercise-induced desaturation) have since emerged.
Oxygen therapy has also gained widespread acceptance by official
organizations for the management of many other chronic cardiores-
piratory conditions complicated by severe hypoxemia, even if proof of
efficacy is lacking (3-5). In addition, oxygen is often prescribed to
alleviate dyspnea in patients receiving palliative care.
Home oxygen therapy is expensive. For instance, in the Canadian
cohort of the Confronting COPD Survey (n=401; mean age 63 years;
51% female; 35 [8.7%] on LTOT), oxygen therapy accounted for 17%
of the entire annual direct costs of COPD care (6). Unfortunately,
Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec
Correspondence Dr Yves Lacasse, Centre de Pneumologie, Institut Universitaire de cardiologie et de pneumologie de Québec, 2725 Chemin
Ste-Foy, Québec, Québec G1V 4G5. Telephone 418-656-4747, fax 418-656-4762, e-mail yves.lacasse@med.ulaval.ca
324 ©2015 Pulsus Group Inc. All rights reserved
L’admissibilité aux programmes d’oxygénothérapie à
domicile et à leur financement au Canada
HISTORIQUE : Même si l’assurance-maladie est généralement univer-
selle au Canada, on constate d’importantes différences dans la prestation
de l’oxygénothérapie à domicile en fonction des régions.
OBJECTIF : Comparer systématiquement les modalités liées à
l’oxygénothérapie à domicile dans les diverses régions du Canada, en
s’attardant sur les critères d’inclusion clinique.
MÉTHODOLOGIE : Les auteurs ont cherché les modalités des dix provinces
et des trois territoires du Canada et se sont attardés aux critères généraux
d’admissibilité à l’oxygénothérapie à domicile (y compris les critères de gaz
sanguins et les critères d’admissibilité à l’oxygénothérapie ambulatoire et
nocturne). Ils ont comparé les critères d’admissibilité aux critères large-
ment acceptés de l’essai sur l’oxygénothérapie nocturne (NOTT), les
recommandations cliniques de la Société canadienne de thoracologie et les
résultats des analyses Cochrane.
RÉSULTATS : Les chercheurs ont extrait les modalités de neuf provinces.
Toutes possèdent des critères similaires pour l’oxygénothérapie à long
terme, malgré de légères différences quant aux seuils d’ordonnance et aux
critères cliniques pour définir « l’hypertension pulmonaire » ou le « cœur
pulmonaire ». La saturation en oxyhémoglobine n’est pas toujours un
critère de financement. Les neuf provinces financent l’oxygénothérapie
nocturne, toutes selon des critères cliniques différents. Le financement des
réservoirs d’oxygène portatifs varie considérablement selon les provinces,
qu’il soit offert aux patients sous oxygénothérapie à long terme ou à ceux
qui souffrent de désaturation isolée causée par l’exercice. Les modalités de
remboursement sont très hétérogènes.
CONCLUSIONS : Les critères d’admissibilité à l’oxygénothérapie à
domicile et à son financement sont hétérogènes au Canada. D’après les
données tirées des publications à jour de plusieurs régions sociosanitaires du
Canada, les modalités de prescription et le remboursement de l’oxygène ne
sont pas toujours offerts.
inappropriate prescriptions of home oxygen are not unusual (7). In
this regard, the American Thoracic Society and the American College
of Chest Physicians identified the prescription of supplemental home
oxygen following hospitalization for an acute illness as one of the top
five tests or interventions that are commonly and incorrectly used at
great expense in adult pulmonary medicine (8).
In Canada, provinces and territories are responsible for delivering
health care services, guided by the provisions of the Canada Health
Act. Although medical insurance is generally universal, we realized,
in our planning of a national trial of nocturnal oxygen therapy in
COPD (the INOX trial; ClinicalTrials.gov NCT01044628), that
significant differences exist in the provision of home oxygen therapy
across the country. These differences are created and maintained
within home oxygen programs by province-specific terms of refer-
ence defining and governing eligibility to equipment, allied services
and reimbursement.
From this observation, we undertook the present study with the
primary objective of systematically comparing the terms of reference to
oxygen therapy across Canada, with a focus on the clinical inclusion
criteria to the programs. Our secondary objective was to confront
these eligibility criteria to the current national COPD clinical practice
guidelines and to the best evidence from the literature. We also sought
to describe the terms of reimbursement across jurisdictions.
Can Respir J Vol 22 No 6 November/December 2015
 Eligibility for home oxygen across Canada

METHODS Table 1
Terms of reference: inclusion and retrieval Terms of reference for home oxygen therapy in Canada
The authors consulted the websites of the ministries or divisions of Last
health for the document reporting on the terms of reference to oxy- Province Document / Policy title revision date
gen therapy of the 10 Canadian provinces and three territories. For British Columbia* Home Oxygen Program (HOP) Application May 2012
validation purposes, whenever necessary, or when no document was BC Home Oxygen Program Medical Eligibility July 2012
available on the Internet, the provincial or territorial division Alberta Alberta aids to daily living. Respiratory Benefits July 2013
responsible for home care programs was directly contacted. As a last Program. Policy & procedures manual
resort, a respirologist involved in the care of patients with COPD
Saskatchewan Saskatchewan aids to independent living January
was contacted to obtain information on the provision of home oxy-
program (SAIL) – General policies 2010
gen in his/her province. To be considered, the documents had to be (Home oxygen program section)
officially endorsed by the provincial or federal governments.
Manitoba Home oxygen concentrator program April 2009
Prescription forms or clinical guides from private oxygen suppliers
(Policy No. HCS 207.7)
were, therefore, excluded.
Ontario Home oxygen therapy policy and April 2014
Data extraction administration manual
From each document, two reviewers (YL and SB) extracted the fol- Quebec Program national d’oxygénothérapie June 2011
lowing information: date of publication; who is accredited to pre- à domicile – Cadre de référence
scribe oxygen; the eligible diagnoses (including COPD and other New Brunswick New Brunswick Extra-mural Program. September
cardiorespiratory conditions); general eligibility criteria for home Provincial policy Manual. Chapter 5. 2008
oxygen (including blood gas criteria, and eligibility criteria to ambu- Section 5.4.3 Home oxygen program –
latory and nocturnal oxygen); eligibility for oxygen therapy in pallia- Medical eligibility criteria
tive care; whether current smokers are eligible to home oxygen; and Nova Scotia Home oxygen service – Procedures September
the terms of reimbursement. & guidelines 2007
Prince Edward Home oxygen program application form Not provided
Comparison with the current Canadian recommendations and Island
international literature *British Columbia is divided in five regional health authorities with their own
General eligibility criteria for LTOT in COPD were compared with assessment committee. They generally adhere to the same guidelines (Dr.
the usual and widely accepted criteria of the Nocturnal Oxygen Jeremy Road, respirologist, Vancouver, personal communication). Only the docu-
Therapy Trial (NOTT): in a period of clinical stability, partial pressure ment from Vancouver Coastal Health was reviewed
of oxygen in arterial blood (PaO2) ≤55 mmHg; or PaO2 ≤59 mmHg
with clinical evidence of at least one of the following: peripheral
edema (cor pulmonale); hematocrit ≥55%; or right ventricular equipment suppliers (eg, Alberta, Manitoba, Ontario, Quebec and
hypertrophy (P pulmonale on electrocardiogram: 3 mm in leads II, Nova Scotia).
III, aVF) (2). The eligibility criteria for nocturnal and ambulatory
oxygen were also correlated with the clinical recommendations put Comparison among terms of reference
forward by the Canadian Thoracic Society (CTS) in its latest prac- Prescriber: In all nine provincial terms of reference, home oxygen
tice guidelines targeting COPD (9). Although this document was can be prescribed by physicians. In two provinces (Manitoba and
published by an official organization, it has no authority on the pro- Nova Scotia), the indication of oxygen must be confirmed by phys-
vision or reimbursement of oxygen in the country. For indications icians designated by regional or provincial authorities. In British
and conditions other than LTOT in COPD, the eligibility criteria for Columbia, Saskatchewan and Ontario, nurse practitioners can also
home oxygen programs were compared with the results of Cochrane prescribe oxygen.
reviews. In this comparison, investigation of the use of oxygen was Eligibility criteria: Details regarding the criteria of funding for long-
limited to two clinical conditions that were selected a priori: inter- term, nocturnal and portable oxygen are provided in Table 2. In seven
stitial lung diseases (10) and palliative care (11). of the nine documents, general criteria apply to any health condition
that may benefit from oxygen therapy, without distinction between
Analysis COPD and other cardiorespiratory diagnoses. In Quebec, specific cri-
The present study was descriptive only. Statistics were limited to pro- teria exist for 10 cardiorespiratory different diagnoses including
portions. No statistical comparisons were involved. COPD. In Alberta, in addition to general eligibility criteria, special
recommendations are provided for hypoventilation syndrome on long-
RESULTS term ventilatory support and for palliative cardiac patients.
Terms of reference (Table 1) All organizations have similar criteria for LTOT. However, slight
The terms of reference for nine of the 10 Canadian provinces were differences exist in the thresholds of prescriptions and in the clini-
retrieved. There is no home oxygen program in Newfoundland, cal criteria defining ‘pulmonary hypertension’ or ‘cor pulmonale’
Yukon, the Northwest Territories (Dr Nigel Duguid, respirolo- when PaO2 is in the range of 56 mmHg to 60 mmHg. The use of
gist, St John’s, Newfoundland; Mrs Heather Alton, Manager, oxyhemoglobin saturation as a criterion for funding is inconsistent
Community Care, Yukon Health and Social Services; Mrs Kim among provinces. Quebec, Nova Scotia and Prince Edward Island
Riles, Director, Territorial Health Services, Department of Health are the only three provinces that do not fund home oxygen on the
and Social Services, Government of Northwest Territories; all per- basis of oxygen saturation alone. The notions of “clinical stability”,
sonal communications) and, presumably, Nunavut (because no one “optimal therapy” and/or “reassessment” if the initial prescription of
at the Department of Health and Social Services in Iqaluit could be oxygen is made during the course of an exacerbation are included in
contacted). With the only exception of the document from Prince the nine documents. All nine provinces fund nocturnal oxygen, all
Edward Island, whose date of publication was not clearly specified, with different clinical criteria. Finally, funding for portable oxygen
all terms of reference were published between 2007 and 2014. The widely varies across provinces, whether the ambulatory equipment is
extent of the documents ranged from a simple application form offered to patients on LTOT or to those who have isolated exercise-
containing the eligibility criteria (eg, Prince Edward Island) to induced desaturation.
comprehensive guides detailing specific criteria to home oxygen Palliative oxygen (Table 3): Even if palliative oxygen is provided in
therapy, terms of reimbursement and responsibilities of private all nine provinces, the criteria for eligibility are heterogeneous.

Can Respir J Vol 22 No 6 November/December 2015 325

Lacasse et al

Table 2
General eligibility criteria for home oxygen
Arterial blood gas Oxygen saturation Portable oxygen for Portable oxygen for
Province (PaO2) criteria (SpO2) criteria Nocturnal oxygen alone patients on LTOT exercise-induced desaturation
British Columbia PaO2 ≤55 mmHg or SpO2 <88% sustained In absence of comorbidities, Funded on evaluation Funded on evaluation
≤60 mmHg with evidence continuously for six daytime desaturation must If client is unable to Hypoxemia on exercise is
of one of the following consecutive minutes be present at rest or with walk ≥1 min, ambulatory defined as an exertional SpO2
condition: chronic heart may be accepted ambulation for nocturnal oxygen will not be useful <88% sustained continuously
failure or pulmonary oxygen therapy to be and will not be funded for a minimum period of
hypertension funded. SpO2 must be 1 min during the patient’s
<88% for >30% of a usual type of ambulation on
minimum 4 h nocturnal a level surface
oximetry study while Evaluation protocol and funding
breathing room air criteria described
Alberta PaO2 ≤55 mmHg or SpO2 ≤89% for 3 consec- At least one episode of On occasion, suppliers may, Funded on evaluation
<60 mmHg, with evi- utive minutes at rest SpO2 ≤83% for 5 min on for convenience purposes, Hypoxemia on exercise is
dence of cor pulmonale accepted as a criteria in level 3 sleep study; no evi- provide a combination of defined as an exertional SpO2
(P pulmonale ECG pat- very specific circum- dence of sleep-disordered systems (eg, concentrator <89% continuously for at least
tern, jugular venous dis- stances (unsuccessful breathing; respiratory dis- and liquid oxygen; liquid one continuous minute.
tension, hepatomegaly, arterial puncture, bed- turbance index <10). If oxygen and cylinders). Evaluation protocol and fund-
peripheral edema), poly- ridden patients). Prior body mass index Clients do not pay extra for ing criteria described
cythemia (hematocrit approval is required. ≥37 kg/m2, a level 1 sleep combination systems.
>55%) or pulmonary Maximum authorization study must be done Suppliers do not charge
hypertension (docu- term is then 3 months, clients for combination
mented by pulmonary with no further exten- systems
artery pressure measure- sion possible)
ment or ultrasound)
Saskatchewan PaO2 ≤55 mmHg or ≤87% for a minimum of SpO2 ≤87% for >30% of Ten portable oxygen Funded upon evaluation
≤59 mmHg in the pres- two consecutive min- the test time cylinders per month are Hypoxemia on exercise is
ence of cor pulmonale or utes or ≤90% in the provided with the oxygen defined as an exertional
polycythemia presence of cor pulmo- concentrator, without SpO2 ≤87% continuously
nale or polycythemia further evaluation for a minimum of 20 s
Evaluation protocol and funding
criteria described
Manitoba PaO2 ≤59 mmHg on Saturation alone not Nocturnal SpO2 ≤85% for Not funded Funded on evaluation
room air accepted as a criteria a significant proportion of Hypoxemia on exercise is
in adults sleep time (5%); severe defined as an exertional
episodes of desaturation SpO2 <90%
on 1 or 2 occasions per Evaluation protocol and funding
night persisting for at least criteria described
5 min. Confirmed by either
polysomnography or respi-
ratory sleep study
Ontario PaO2 ≤55 mmHg or PaO2 SpO2 ≤88% or 89–90% Individuals with PaO2 Funded on evaluation Funded on evaluation
in the range of 56–60 if one of the following 56–60 mmHg (SpO2 The oxygen supply system Hypoxemia on exercise is
mmHg if one of the fol- is present: cor pulmo- 89–90%) may be candi- is determined by the pre- defined as an exertional
lowing is present: cor nale, pulmonary hyper- dates for funding if noctur- scriber in consultation with SpO2 ≤88%
pulmonale, pulmonary tension or persistent nal hypoxemia is present the client and, if necessary, Evaluation protocol and funding
hypertension or erythrocytosis (nocturnal hypoxemia not another regulated health criteria described
persistent erythrocytosis defined). The prescribed professional. They should
must submit a formal take into account the oxy-
sleep study report to rule gen prescription, mobility
out sleep-disordered needs and the cost effec-
breathing that may be tiveness of the modality
treatable by other means
Quebec PaO2 ≤55 mmHg; PaO2 Saturation alone not SpO2 <90% for >30% of Funded on clinical evalua- Not funded
≤59 mmHg with periph- accepted for eligibility recording time, if clinical tion only; funded if the
eral edema, hematocrit assessment evidence of right heart fail- patient is able to go out of
≥55%, and/or P pulmo- ure or significant nocturnal his/her home ≥4 h/week,
nale on ECG arythmias are noted has exercise-induced
desaturation (< 85% on a
6 min walk test, and
improves saturation
(>90%) on a repeat walk
test performed with ambu-
latory oxygen
Continued on page 327

326 Can Respir J Vol 22 No 6 November/December 2015

 Eligibility for home oxygen across Canada

Table 2 – continued
General eligibility criteria for home oxygen
Arterial blood gas Oxygen saturation Portable oxygen for Portable oxygen for
Province (PaO2) criteria (SpO2) criteria Nocturnal oxygen alone patients on LTOT exercise-induced desaturation
New Brunswick PaO2 <55 mmHg or PaO2 SpO2 <89% on room Polysomnography or Not mentioned Exertional desaturation must
56–59 mmHg in addition air is accepted on nocturnal oximetry must be confirmed by oximetry
to evidence of cor reassessment (com- confirm nocturnal desatu- studies on room air (SpO2
pulmonale, pulmonary pleted within 3 months ration (SpO2 <89% on <89% while performing usual
hypertension or second- of initial prescription) room air for at least activities of daily living)
ary polycythemia 5 min)
(hematocrit >55%)
Nova Scotia PaO2 <55 mmHg or in SpO2 level must be Nocturnal desaturation con- Portable oxygen cylinders Funded on evaluation
the range of 56–59 ≤89% firmed by polysomnogra- provided (to a maximum Testing must demonstrate
mmHg with evidence of phy or nocturnal oximetry of 10 cylinders per month) desaturation to a SpO2
cor pulmonale (P pulmo- tests (severe episodes of ≤80%, regardless of
nale ECG pattern, jugu- arterial desaturation on 1 dyspnea or distance walked
lar venous distension, or 2 occasions per night,
tender liver, peripheral persisting ≥2 min. This
edema), or secondary type of individual spends
polycythemia (hematocrit at least 5% of sleep time
>55%) with SpO2 ≤85% without
nocturnal oxygen therapy
Prince Edward PaO2 ≤55 mmHg or in the Saturation alone not Nocturnal desaturation with Portable oxygen cylinders Not funded
Island range of 56–59 mmHg accepted for eligibility ≥5% of sleep time with an provided (maximum:
and evidence of cor pul- assessment SpO2 ≤85% (confirmed by 10 cylinders per month)
monale, secondary poly- polysomnography or a
cythemia (hematocrit sleep screening study
>55%) or pulmonary including continuous oxy-
hypertension (confirmed gen saturation, heart rate
by evidence of pulmo- and direct measurement
nary artery pressure or of airflow. Obstructive
ultrasound indicating sleep apnea or periodic
elevated pulmonary breathing must be
artery pressure) excluded)
ECG Electrocardiogram; LTOT Long-term oxygen therapy; PaO2 Partial pressure of oxygen in arterial blood

Clinical indications, saturation criteria, period of funding and condi-
tions of prescription renewal are all different. In Saskatchewan, cover-
age even includes portable oxygen cylinders.
Oxygen in current smokers (Table 4): Saskatchewan is the only
province where no specific instruction is given when oxygen is pre-
scribed to current smokers. In all eight other documents, restrictions to
home oxygen therapy in smokers are more or less directive. Nova
Scotia has the strictest restrictions.
Comparison with current Canadian recommendations and the
international literature
In all nine documents, criteria for LTOT are based on the inclusion
criteria of the NOTT trial (2), which are also supported by the CTS
(9). Slight differences exist in the thresholds of prescriptions and the
NOTT’s clinical criteria defining pulmonary hypertension or cor pul-
monale when PaO2 is in the range of 56 mmHg to 60 mmHg.
Although nocturnal and portable oxygen is funded everywhere, the
CTS does not support the use of nocturnal oxygen in patients with
isolated nocturnal desaturation, or the provision of ambulatory oxygen
to patients with COPD.
In the nine terms of reference, oxygen for patients with interstitial
disease is based on the same general eligibility criteria as those with
COPD. In Cochrane reviews, the assumption that home oxygen therapy
has a beneficial survival effect in patients with interstitial lung disease
has not been demonstrated in the single randomized controlled trial
identified by Crockett et al (10). Similarly, although palliative oxygen is
funded everywhere, in cancer patients, it failed to demonstrate a benefi-
cial effect over air breathing, although this conclusion was limited by
the small volume of research studies available for inclusion (11).
Terms of reimbursement
Patients receive full funding in five provinces (British Columbia,
Alberta, Manitoba, Saskatchewan and Quebec). In Ontario, full
funding is provided for patients ≥65 years of age; with few exceptions,
75% of the monthly rate is reimbursed for those <65 years of age. In
New Brunswick, an amount of $100 per month is reimbursed for the
concentrator for individuals ≥65 years of age; palliative oxygen is
funded on a discretionary basis, and portable cylinders are provided
for medical appointments only. In Nova Scotia, the funding program
will pay approved vendors for the services provided in accordance
with a detailed schedule (eg, $200 per client per month for standard
concentrator and related supplies, and $18 per portable cylinder).
Similarly, in Prince Edward Island, financial assistance is up to 50% of
the approved home oxygen expenses, to a maximum of $200 per
month. Although not explicitly stated in most documents (with the
exception of British Columbia, Ontario, Quebec and Nova Scotia), it
was assumed that public funding for equipment and allied services was
available only for those without any other source of benefits (such as
private insurance plans, coverage from Veterans Affairs Canada or
the Health Canada’s Non-Insured Health Benefits Program (Table 5).
The latter provides home oxygen to eligible registered First Nations
and recognized Inuit, when it is not already provided through private
insurance plans, provincial or territorial health and social programs,
or other publicly funded programs.
In jurisdictions where no home oxygen program exists, oxygen
may be obtained from different sources of funding. An example is
in the Northwest Territories, where the Department of Health and
Social Services has extended health benefit programs that provide
full funding support for the purchase or rental of home oxygen,
oxygen supplies and equipment. These programs require previous

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Lacasse et al
Table 3
Palliative oxygen
Province Eligibility criteria
British Columbia Palliative diagnosis does not ensure home oxygen
subsidy. Palliative clients must have hypoxemia
according to the same criteria as for resting oxygen,
ambulatory oxygen or nocturnal oxygen to be funded.
Alberta Approved if room air SpO2 <90% at rest during the day-
time for at least 3 continuous minutes. “Palliative” must
be written on the physician’s prescription. The maxi-
mum authorization is for six months, and will only be
extended for one six-month (maximum) period.
Saskatchewan The time frame for end-stage care may be measured in
terms of days or weeks of active dying.
Eligibility is according to symptoms and performance
status (not saturation).
Coverage includes a concentrator and 10 portable oxygen
cylinders per month. Funding is for a maximum of four
months; only a prescription is required to renew coverage.
Manitoba Assessment for home oxygen therapy for a palliative
care client conforms to the same medical eligibility
criteria as those for resting hypoxemia.
Ontario Funded for individuals who are at the end stage of a termi-
nal illness (ie, life expectancy <3 months), are receiving
end-of-life care and require home oxygen therapy.
Funding is provided for a maximum period of 90 days.
Quebec Palliative oxygen may be considered if severe hypoxemia
is present (saturation at rest <88%) in a patient with
lung cancer or any other cancer with pulmonary
involvement, if vital prognosis is estimated to be
<3 months.
For non-neoplastic conditions, palliative oxygen may be
considered if severe hypoxemia is present (PaO2
≤55 mmHg, or <60 mmHg in case of right heart failure).
New Brunswick For end-stage palliative patients, in whom terminal illness
affects the respiratory system; SpO2 studies confirm oxy-
gen desaturation with SpO2 <89% on room air.
Nova Scotia The home oxygen service does not provide funding
assistance for home oxygen therapy when prescribed
for psychological support of for breathlessness
unsupported by evidence of hypoxemia.
Prince Edward Palliative care with a minimum of two oximetry results
Island showing a % saturation <85% and requiring oxygen
therapy for at least 18 h per day
PaO2 Partial pressure of oxygen in arterial blood; SpO2 Oxygen saturation
approval through Alberta Blue Cross, who administer the extended
health benefit programs, and use the same guidelines as the Non-
Insured Health Benefits Program.
DISCUSSION
Our study uncovered heterogeneity in the criteria for eligibility for
home oxygen programs and funding across Canada. More importantly,
our findings indicate that the available evidence from the current lit-
erature does not necessarily translate into the terms of prescription and
reimbursement of oxygen in several Canadian jurisdictions.
Reimbursement for home oxygen may be quite different from one
province to another. Our study also demonstrates that despite the CTS
guidelines published in 2007, health care payers maintain their deci-
sion to fund, at least in COPD, nocturnal and ambulatory oxygen even
if the evidence to support both interventions is lacking.
Of course, areas of agreement exist, with only minor differences
in the thresholds of prescription for patients with daytime resting
hypoxemia and in the definition of pulmonary hypertension and cor
pulmonale” when PaO2 is in the range of 56 mmHg to 59 mmHg.
Also, all nine documents support the prescription of nocturnal oxygen;
328
Table 4
Home oxygen in current smokers
Province Recommandations
British Columbia Smokers who do not comply with safety instructions will
be at risk of having oxygen funding discontinued imme-
diately and doctor notified. Home oxygen program will
not provide client with funding after the second reported
safety offence
Alberta Supplier’s respiratory therapist “advise clients not to
smoke when using oxygen”
Home oxygen may be discontinued “if smoking habit
endangers the safety of self or others. This must be
documented on the file and the client’s physician
informed”
Saskatchewan No specific mention about smoking
Manitoba “The client and/or caregiver(s) agree(s) to adhere to safe
practices relative to delivery of oxygen therapy. There
should be no smoking, heat source or open flames within
3 meters (10 feet) of oxygen.”
Ontario “The applicant’s medical condition must be stabilized
and treatment regimen optimized before home oxygen
therapy is considered. Optimum treatment includes
smoking cessation.”
Quebec Long-term oxygen therapy is not indicated in patients with
severe hypoxemia who are current smokers
In patients who stopped smoking only recently, 4 weeks
of observation should be considered to ascertain smok-
ing cessation before oxygen therapy is started
New Brunswick The individual has an optimal medical program (defined
as the medical treatment that stabilizes/reduces symp-
toms as much as possible and should include smoking
cessation) in effect at the time of medical assessment
for home oxygen therapy
Nova Scotia An applicant is not eligible if he or she is a smoker
An applicant is not eligible if he or she refuses to sign a
nonsmoking agreement or, in the case of pediatric cli-
ents, if the parent or guardian refuses to sign a non-
smoking agreement
Clients who are in receipt of home oxygen services and
who are determined to be noncompliant with no smok-
ing requirements, will have funding for the service dis-
continued for a minimum period of 3 months
Prince Edward Patients must certify that “there is no smoking allowed
Island within my home or apartment”
however, with more important differences in the definition of noctur-
nal desaturation. Areas of disagreement are significantly more com-
mon when the indication or practice of oxygen therapy is not clearly
evidence based. Examples include the use of oxyhemoglobin satura-
tion as a criterion for funding and the restrictions to the prescription
of oxygen to current smokers. The provision of portable cylinders to
oxygen-dependent patients or for isolated exercise-induced desatura-
tion and the conditions of reimbursement of oxygen in palliative
care are other areas of controversy, although they correspond to
issues that have been well addressed in randomized controlled tri-
als and in meta-analyses that demonstrated the limitations of these
interventions (12-17).
Even if it is expensive and, in several circumstances, of unproven
efficacy, why is oxygen so easily reimbursed? One explanation may be
that, in addition to being safe and readily available, the prescription of
oxygen always makes sense: if oxygen desaturation exists, its correction
should help. This reasoning was common before the introduction of
‘evidence-based medicine’, when the study and understanding of basic
mechanisms of disease and pathophysiological principles were con-
sidered sufficient to guide clinical practice (18). However, numerous
Can Respir J Vol 22 No 6 November/December 2015
 Eligibility for home oxygen across Canada

Table 5
General eligibility criteria for home oxygen in two federal funding programs
Prescriber
Arterial blood gas (PaO2) criteria
Oxygen saturation criteria
Nocturnal oxygen alone
Portable oxygen for patients on LTOT
Portable oxygen for exercise-induced
desaturation
Palliative oxygen
Restriction for current smokers
*Veterans Affairs Canada. Oxygen Therapy and Respiratory Equipment (Program of choice 9). May 2012; †Health Canada. Provider guide for medical supplies and
equipment (MS&E) benefits. Non-Insured Health Benefits. April 2009. LTOT Long-term oxygen therapy; PaO2 Partial pressure of oxygen in arterial blood
Veterans Affairs Canada* Non-Insured Health Benefits†
A request for approval of LTOT must include reports from a Physicians
physician and a respiratory therapist who must include a
description of the equipment necessary to fulfill the pre-
scription and arterial blood gas data
PaO2 ≤55 mmHg; or PaO2 ≤60 mmHg with cor pulmonale, PaO2 ≤55 mmHg, or PaO2 56–59 mmHg with cor pul-
secondary polycythemia or pulmonary hypertension monale, pulmonary hypertension and/or secondary
polycythemia
When a client lives >30 min from an arterial blood gas labora- Saturation alone not accepted for eligibility assessment
tory setting or hospital where an arterial blood gas can be
done, and travel to this centre is not feasible, an oximetry
reading may be substituted using room air. The oximetry
must indicate a level of saturation of ≤88% while awake and
at rest for at least 5 min before oximetry is performed
Nocturnal desaturations must be confirmed by a Saturation <88% for 30% of the night, if daytime
polysomnography or oximetry completed in a sleep PaO2 56–59 mmHg
laboratory, or by a sleep screening study. Nocturnal
desaturation: ≥5% of sleep time with an oxygen saturation
≤85% without nocturnal oxygen therapy
Portable oxygen units (small cylinders of compressed oxygen Funded for a maximum of 8 h per day away from the
or liquid oxygen) are approved for those clients who meet principle residence
the criteria for LTOT who have led an active lifestyle prior
and up to their need for oxygen and who require continuous
oxygen to remain ambulatory outside the home or to main-
tain regular routines
Exercise-induced oxygen desaturation will not be recog- Not funded
nized for LTOT except in exceptional circumstances. All
of these cases would have to be individually medically
judged by the Senior District Medical Officer with appro-
priate preauthorization
Provided in exceptional cases for terminally ill clients who Life expectancy <3 months with persistent hypoxemia
do not otherwise meet the approval criteria. In such cases (PaO2 ≤60 mmHg or saturation ≤92% or dyspnea that
the approval of long-term home oxygen should be cannot be improved with medication and/or comfort
reconsidered after 3 months analgesia
The Department will not be held responsible for any injury or Not mentioned
damages resulting from the use of long-term home oxygen
and smoking

examples proved the contrary. For instance, although oxygen corrects
oxygen desaturation and improves walked distance in patients with
COPD and exercise-induced desaturation in laboratory testing (19),
several trials have failed to demonstrate long-term benefits of this
therapy (14-17).
Terms of reference are not practice guidelines. Nevertheless, in a
jurisdiction where medical insurance is universal, they can be assimi-
lated to an insurance contract: they are powerful in delineating medical
practice and prescriptions, and have an important financial impact.
Funding of effective interventions depends on the maximum cost-
effectiveness ratio the payer is willing to accept. Funding of interven-
tions that proved ineffective is a waste of money and resources for both
the insurer and the policyholders. Funding of interventions of unknown
or uncertain efficacy is debatable. This latter situation has at least one
pernicious consequence: it is an obvious obstacle to further research.
Such has been our own experience with the INOX trial in which
recruitment has been stopped after an interim analysis in December
2014. We often faced the reluctance of patients and sometimes clini-
cians we had invited to participate as coinvestigators to engage into the
trial, arguing that nocturnal oxygen therapy is available anyway.
Our study had limitations. It only investigated administrative
documents. It did not provide insight into clinical practice and does
not inform clinical outcomes. The rigour in the reinforcement of the
terms of reference is also unknown. In this regard, the results of a study
indicated that, in 2000, 96 of 237 patients (41%) receiving domiciliary
oxygen in the Ontario Ministry of Health Home Oxygen Program did
not meet criteria for home oxygen (7). Whether the situation has since
improved is unknown. We have no reason to believe that the situation
was better elsewhere in the country when this study was conducted.
The results of our study call for action. Most terms of reference
defining and governing eligibility to home oxygen equipment, allied
services and reimbursement need in-depth revision. In addition to
being evidence based, all terms of reference should also be regularly
updated. Because health is under provincial jurisdiction in Canada,
national terms of reference cannot be created. Closer monitoring of
the prescriptions of home oxygen is also mandatory (8). Accordingly,
provincial and national registries of patients on home oxygen should
be created. Such registries would be useful in the conduct of clinical
and epidemiological research, and to document variations in
approaches to the prescription of LTOT. Finally, all efforts to gener-
ate evidence regarding the effect of oxygen therapy on survival and
quality of life as well as its cost-effectiveness in a variety of condi-
tions and indications must be encouraged. Such efforts are challeng-
ing because they require time, money and commitment from the
investigators, the clinicians, the patients and their families to bring
the clinical trials to their end. However, this investment is certainly
worth it for the patients and those who will have to financially sup-
port home oxygen therapy.

Can Respir J Vol 22 No 6 November/December 2015 329

 Lacasse et al
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